Frailty in CKD and Transplantation

Current status and development trends in CKD with frailty research from 2000 to 2021: a bibliometric analysis

INTRODUCTION

The prevalence of chronic kidney disease (CKD) is gradually increasing in the elderly population. At the same time, frailty has become one of the research hotspots in the field of geriatrics. Bibliometric analyses help to understand the direction of a field. Therefore, this study aimed to analyze the status and emerging trends of frailty in CKD patients.

DATA AND METHODS

The Web of Science Core Collection (WoSCC) database was screened for relevant literature published between 1 January 2000 and 31 December 2021. Next, publications were analyzed for information including authors, journals, cited references, citing journals, institutions, countries and regions, high-frequency keywords and co-citations using VOSviewer, Microsoft Excel, and R software.

RESULTS

A total of 2223 articles were obtained, from which 613 relevant articles were selected based on title and abstract screening. There was an upward trend in the number of annual publications and Johansen KL was considered the most contributing author in the field. The Clinical Journal of the American Society of Nephrology was the most productive research journal. Johns Hopkins University is the most published organization. The United States is the global leader in the field and contributes the most to research. Research hotspots focus on epidemiological studies of frailty and frailty intervention.

CONCLUSIONS

This study presents a comprehensive bibliometric analysis of CKD and frailty research. Key findings highlight the current focus on early screening and assessment of frailty in CKD patients, as well as physical function interventions in frail patients.

Treatment of chronic kidney disease in older populations

As the world population ages, an expected increase in the prevalence of chronic kidney disease (CKD) among older individuals will pose a considerable challenge for health care systems in terms of resource allocation for disease management. Treatment strategies for older patients with CKD should ideally align with those applied to the general population, focusing on minimizing cardiovascular events and reducing the risk of progression to kidney failure. Emerging therapies, such as SGLT-2 inhibitors and GLP-1 receptor agonists, hold promise for the effective management of CKD in older individuals. In addition, non-pharmacological interventions such as nutritional and exercise therapies have a crucial role. These interventions enhance the effects of pharmacotherapy and, importantly, contribute to the maintenance of cognitive function and overall quality of life. Various factors beyond age and cognitive function must be taken into account when considering kidney replacement therapy for patients with kidney failure. Importantly, all treatment options, including dialysis, transplantation and conservative management approaches, should be tailored to the individual through patient-centred decision-making. The dynamic integration of digital technologies into medical practice has the potential to transform the management of CKD in the aging population.

Prospective Cohort Study Examining the Ability of Performance-Based and Self-Reported Frailty Measures to Predict 30-Day Rehospitalizations After Kidney Transplantation

Performance-based measures of frailty are associated with healthcare utilization after kidney transplantation (KT) but require in-person assessment. A promising alternative is self-reported frailty. The goal of this study was to examine the ability of performance-based and self-reported frailty measures to predict 30-day rehospitalizations after KT. We conducted a prospective, observational cohort study involving 272 adults undergoing KT at Mayo Clinic in Minnesota, Florida, or Arizona. We simultaneously measured frailty before KT using the physical frailty phenotype (PFP), the short physical performance battery (SPPB), and self-report (the Patient-Reported Outcomes Measurement Information System [PROMIS] 4-item physical function short form v2.0). Both the PFP and self-reported frailty were independently associated with more than a 2-fold greater odds of 30-day rehospitalizations, while the SPPB was not. To our knowledge, this is the first study to assess the prognostic value of all three of the above frailty measures in patients undergoing KT. The PFP is more prognostic than the SPPB when assessing the risk of 30-day rehospitalizations; self-reported frailty can complement the PFP but not replace it. However, the 4-item survey assessing self-reported frailty represents a simple way to identify patients undergoing KT surgery who would benefit from interventions to lower the risk of rehospitalizations.

Biomarkers of chronic kidney disease in older individuals: navigating complexity in diagnosis

Chronic kidney disease (CKD) in older individuals is a matter of growing concern in the field of public health across the globe. Indeed, prevalence of kidney function impairment increases with advancing age and is often exacerbated by age-induced modifications of kidney function, presence of chronic diseases such as diabetes, hypertension, and cardiovascular disorders, and increased burden related to frailty, cognitive impairment and sarcopenia. Accurate assessment of CKD in older individuals is crucial for timely intervention and management and relies heavily on biomarkers for disease diagnosis and monitoring. However, the interpretation of these biomarkers in older patients may be complex due to interplays between CKD, aging, chronic diseases and geriatric syndromes. Biomarkers such as serum creatinine, estimated glomerular filtration rate (eGFR), and albuminuria can be significantly altered by systemic inflammation, metabolic changes, and medication use commonly seen in this population. To overcome the limitations of traditional biomarkers, several innovative proteins have been investigated as potential, in this review we aimed at consolidating the existing data concerning the geriatric aspects of CKD, describing the challenges and considerations in using traditional and innovative biomarkers to assess CKD in older patients, highlighting the need for integration of the clinical context to improve biomarkers' accuracy.

The Impact of Frailty and Severe Cognitive Impairment on Survival Time and Time to Initiate Dialysis in Older Adults With Advanced Chronic Kidney Disease: A Prospective Observational Cohort Study

Background and objectives Frailty and cognitive impairment significantly impact survival time and time to initiate dialysis in older adults with advanced chronic kidney disease (CKD). This study aims to evaluate the effects of frailty and cognitive impairment on these outcomes and determine the most effective assessment tool for predicting early dialysis initiation and short survival time. Materials and methods This prospective observational cohort study involved 240 patients aged ≥65 years with stage 4 or 5 CKD, recruited from a nephrology outpatient department (ambulatory care) between March 2020 and March 2021. Frailty was assessed using the Physical Frailty Phenotype (PFP), PRISMA-7, Clinical Frailty Scale (CFS), and FRAIL scale. Cognitive function was evaluated using the Montreal Cognitive Assessment (MoCA). The primary outcomes were time to initiate dialysis and survival time, with secondary outcomes including hospitalization rates, length of stay, and mortality after dialysis initiation. Results Frail patients only showed significantly shorter time to dialysis initiation when identified by the PFP and FRAIL scale (28.3 months for frail vs. 31.2 months for non-frail, p = 0.028; 26.9 months for frail vs. 30.9 months for non-frail, p = 0.038). The PFP, FRAIL, and CFS tools indicated significantly shorter survival times for frail patients compared to non-frail patients (26.8 months for frail vs. 30.6 months for non-frail, p = 0.003). Frailty is strongly correlated with severe cognitive impairment, as 45.5% of frail patients (according to the FRAIL scale) have dementia compared to 15.1% of non-frail patients (p<0.001). However, cognitive impairment did not significantly affect the time to dialysis initiation or survival time. Hospitalization rates and length of stay in the hospital were significantly higher only for frail patients identified by PRISMA-7, with a median hospital length of stay of 9.15 days for frail patients vs 6.37 days for non-frail patients (p = 0.044). Overall, 37.5% of the patients did not survive during the study follow-up, with frail patients having a higher mortality rate. Conclusion Frailty, mainly when assessed by PFP and FRAIL, is a significant predictor of early dialysis initiation and reduced survival time in older adults with advanced CKD. Cognitive impairment, while prevalent, did not independently predict these outcomes. Regular frailty screening should be incorporated into CKD management to tailor interventions and improve patient outcomes.

Unmet Questions About Frailty in Kidney Transplant Candidates

Frailty occurs frequently among patients with advanced chronic kidney disease, especially among women. Assessing frailty in kidney transplant (KT) candidates is crucial for informing them about associated risks. However, there is poor agreement between frailty scales and research on their correlation with transplant outcomes. Being prefrail significantly impacts both graft and patient survival, often beginning with just 1 Fried criterion. Rather than viewing frailty as a categorical state, it should be regarded as a spectrum ranging from 1 to 5 criteria, with the risk of adverse outcomes escalating as frailty worsens. Frailty status fluctuates during the waiting period for KT; hence, a 1-time frailty evaluation is insufficient to determine risks and implement strategies for improving functional status. Further research should investigate the components of frailty that most frequently change during this waiting period and establish strategies to prevent or reverse frailty. Although careful evaluation of frail KT candidates is necessary to prevent early complications and mortality, exclusion based solely on a frailty score is unwarranted. Instead, efforts should focus on timely interventions to enhance their condition before transplantation. Although evidence is limited, exercise programs appear feasible and yield positive results. A pretransplant clinical framework encompassing multimodal prehabilitation-comprising physical therapy, nutritional measures, and psychological support-during the waiting list period may help alleviate the effects of frailty and poor fitness after KT, ultimately improving key outcomes. Despite logistical challenges, there is a pressing need for interventional trials in this area.

The role of depression between sleep disorders and frailty among elderly patients with chronic kidney disease (CKD) in China: a cross-sectional study

OBJECTIVE

To investigate the correlation among sleep disorders, physical frailty, and depression in elderly patients with chronic kidney disease (CKD), and to explore the mediating role of depression.

METHODS

This was a cross-sectional study, simple sampling was used to investigate the elderly CKD patients from one tertiary hospital in Shanghai. Those CKD patients who were diagnosed as CKD1-5 phase and were admitted to the Renal Medicine Ward from January to June 2022 and provided formal consent were considered for inclusion in our study. They were investigated with frailty phenotype (FP), Pittsburgh sleep quality index (PSQI), Center for Epidemiological Studies Depression Scale (CES-D), and self-made general information questionnaire. Linear regression was used to assess the associations between the variables, before this, PROCESS v4.1 was used to transform PSQI, CES-D and FP score to improve its normality, and conduct intermediary analysis. A difference of p < 0.05 was statistically significant.

RESULTS

A total of 504 elderly patients with CKD completed the questionnaire survey, aged 60-91. The incidence of sleep disorders among elderly patients with CKD was 60%, and the incidence of physical frailty was 18%. The depression was positively correlated with physical frailty (r = 0.418, p < 0.01) and sleep disorders (r = 0.541, p < 0.01). Physical frailty was positively correlated with sleep disorders (r = 0.320, p < 0.01). The depression plays a significant mediating role in the model, and the effect ratio of depression is 52%.

CONCLUSION

Depression is a mediating variable between sleep disorders and frailty. Improving depression in elderly patients with CKD accompanied by sleep disorders can help delay the occurrence of frailty.

[Frailty as a predictor of 3-year mortality in older adult patients in long-term care in Mexico]

INTRODUCTION

The objective of our study was to evaluate the long-term association between mortality and frailty in institutionalized patients in Mexico. Worldwide, there are limited lines of research in this population of geriatric patients and this entity generates a significant impact on the quality of life and prognosis of our patients.

MATERIAL AND METHODS

It is a prospective cohort study of 81 patients in long-term care who met the selection criteria. Frailty was determined using the FRAIL scale. Data on mortality were collected during the follow-up period, and diagnosis was monitored. The risk of presenting this event was determined by logistic regression, Kaplan-Meier, and Cox proportional hazards analysis, adjusted for age and sex.

RESULTS

The mean follow-up time of the patients was 36 months (1094 days), during which 33 subjects died (40.7%). In our population, at the beginning of the study the vast majority of frail patients had pathologies that independently generate risk of adverse events, disability (Barthel=30.9; SD 28.8), sarcopenia (n=40; 71.4%), one to 3 falls in the last year (n=17; 63%), ≥4 falls (n=4; 57.1%). Frail participants had a higher adjusted risk of mortality (HR 2.93; 95% CI 1.33-6.43; p=0.007).

CONCLUSIONS

The frailty entity is associated in the long term with mortality in institutionalized patients in Mexico. Timely treatment and approach may allow a good prognosis and quality of life.

Pretransplant Malnutrition, Particularly With Muscle Depletion Is Associated With Adverse Outcomes After Kidney Transplantation

Background

Kidney transplant centers lack consistent diagnostic malnutrition tools. The Academy of Nutrition and Dietetics and American Society of Parenteral Nutrition Adult Malnutrition Criteria (AMC) is the widely accepted and utilized tool by Registered Dietitian Nutritionists (RDNs) to diagnose malnutrition.

Methods

In this single-center, retrospective observational study, we evaluated the outcomes of prekidney transplant malnutrition based on Academy of Nutrition and Dietetics and American Society of Parenteral Nutrition AMC, as well as the individual components of the AMC, on posttransplant outcomes including length of stay, delayed graft function (DGF), early readmission, cardiovascular events, acute rejection, death-censored graft failure, and death. Bivariable and multivariable logistic regression models were used to assess the association of malnutrition or its components with outcomes of interest.

Results

A total of 367 recipients were included, of whom 36 (10%) were malnourished (23 moderately and 13 severely) at pretransplant evaluation. In adjusted models, pretransplant malnutrition was significantly associated with increased risk for early readmission (adjusted odds ratio 2.86; 95% confidence interval: 1.14-7.21; P = 0.03) and with DGF (adjusted odds ratio 8.33; 95% confidence interval: 1.07-64.6; P = 0.04). Muscle depletion was also associated with an increased risk for readmission and with DGF. Fat depletion and reduced functionality in the adjusted model were only associated with increased risk for readmission.

Conclusions

Malnutrition could be an important consideration for selecting kidney transplant recipients because it was associated with poor clinical outcomes. A multidisciplinary approach with the involvement of RDNs to outline a nutrition intervention plan may help mitigate some of the poor outcomes.

Association of Frailty With Nutritional Status in Patients With Chronic Kidney Disease

OBJECTIVES

Frailty is commonly observed in patients with chronic kidney disease (CKD) and is associated with adverse outcomes. Protein-energy wasting (PEW), a state of decreased body stores of protein and energy fuels, may be associated with frailty. However, few data are available on the possible association between frailty and PEW in CKD.

METHODS

We examined the association between frailty and nutritional status assessed using anthropometric and body composition measurements, serum albumin, handgrip strength, the Malnutrition Inflammation Score (MIS), and dietary protein and calorie intake in a cross-sectional analysis of nondialysis patients with CKD stages 3-5. Body composition was assessed using multifrequency bioelectrical impedance. Frailty was defined as a Clinical Frailty Scale ≥4. We performed logistic regression with different nutrition assessment tools as the main predictors and age, sex, comorbidity, estimated glomerular filtration rate (eGFR), and hemoglobin as covariates.

RESULTS

A total of 157 patients (93 men and 64 women; mean age 64 years; diabetes prevalence 38.9%) with CKD (eGFR 24.4 ± 13.4 mL/min/1.73 m2) were included. Overall, 29.3% of patients were frail. Patients with frailty were older and had a significantly higher fat tissue index and MIS but a significantly lower lean tissue index, eGFR, hemoglobin value, serum albumin value, handgrip strength value, and dietary protein intake. In multivariate logistic regression analyses, a higher body mass index category (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.03-2.31), higher fat tissue index (OR, 1.15; 95% CI, 1.03-1.28), larger waist circumference (OR, 1.05; 95% CI, 1.01-1.09), reduced handgrip strength (OR, 2.70; 95% CI, 1.17-6.21), PEW defined by MIS ≥5 (OR, 3.49; 95% CI, 1.35-9.01), and dietary protein intake ≤0.8 g/kg/day (OR, 2.70; 95% CI, 1.18-6.19) were associated with higher odds of frailty.

CONCLUSION

Frailty is associated with nutritional status in patients with CKD. A comprehensive nutrition assessment may allow the implementation of strategies to prevent or reduce frailty.

The prevalence and influencing factors of frailty in patients with chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

To investigate the prevalence and influencing factors of frailty and pre-frailty in chronic kidney disease (CKD) patients and thereby provide a scientific basis for effective avoidance of frailty in patients with CKD.

METHODS

PubMed, EMBASE, Web of Science, EBSCO, Cochrane Library, CNKI, VIP, CBMdisc, and Wanfang databases were searched for relevant studies published till December 31, 2021. The summary results were described as odds ratios (ORs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs). A meta-analysis was performed using StataSE12.0.

RESULTS

Fifteen published studies, which enrolled a total of 3294 CKD patients, met the inclusion criteria. The combined prevalence of frailty in CKD patients was 38.1% (95% CI 29.7-46.5%) and pre-frailty was 37.9% (95% CI 32.7-43.1%). The main factors influencing frailty in CKD patients were age (SMD 0.524, 95% CI 0.326-0.723), diastolic blood pressure (SMD - 0.294, 95% CI - 0.518 to - 0.071), body mass index (BMI) (SMD - 0.267, 95% CI - 0.471 to - 0.064), grip strength (SMD - 0.929, 95% CI - 1.233 to - 0.626), hemoglobin level (SMD - 0.346, 95% CI - 0.448 to - 0.243), serum albumin level (SMD - 0.533, 95% CI - 0.655 to - 0.411), Charlson Comorbidity Index (SMD 0.421, 95% CI 0.150-0.692), multiple medications (SMD 0.625, 95% CI 0.354-0.895), Mini-Mental State Examination (MMSE) score (SMD - 0.563, 95% CI - 0.846 to - 0.280), and female (OR 2.391, 95% CI 1.236-4.627).

CONCLUSION

Frailty is common in CKD patients. The prevalence of frailty among CKD patients was related to age, diastolic blood pressure, BMI, grip strength, hemoglobin and serum albumin levels, Charlson Comorbidity Index, multiple medications, MMSE score, and female.

A machine learning-based assistant tool for early frailty screening of patients receiving maintenance hemodialysis

PURPOSE

To develop an assistant tool based on machine learning for early frailty screening in patients receiving maintenance hemodialysis.

METHODS

This is a single-center retrospective study. 141 participants' basic information, scale results and laboratory findings were collected and the FRAIL scale was used to assess frailty. Then participants were divided into the frailty group (n = 84) and control group (n = 57). After feature selection, data split and oversampling, ten commonly used binary machine learning methods were performed and a voting classifier was developed.

RESULTS

The grade results of Clinical Frailty Scale, age, serum magnesium, lactate dehydrogenase, comorbidity and fast blood glucose were considered to be the best feature set for early frailty screening. After abandoning models with overfitting or poor performance, the voting classifier based on Support Vector Machine, Adaptive Boosting and Naive Bayes achieved a good screening performance (sensitivity: 68.24% ± 8.40%, specificity:72.50% ± 11.81%, F1 score: 72.55% ± 4.65%, AUC:78.38% ± 6.94%).

CONCLUSION

A simple and efficient early frailty screening assistant tool for patients receiving maintenance hemodialysis based on machine learning was developed. It can provide assistance on frailty, especially pre-frailty screening and decision-making tasks.

Sarcopenia and frailty in inflammatory bowel disease: Emerging concepts and evidence

Sarcopenia is a condition marked by progressive loss of skeletal muscle mass and function while frailty is a multidimensional concept characterized by diminished physiological reserve and increased vulnerability to stressors. Both of these were previously considered as related to aging and shown to impact the quality of life and carry prognostic significance. Emerging data show that both sarcopenia and frailty carry similar relevance in chronic illness. Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the gastrointestinal tract and malnourishment, both of which contribute to the development of sarcopenia by increasing protein breakdown and reducing protein synthesis. The coexistence of frailty further compounds the clinical complexity of IBD patients. Published evidence suggests a bidirectional association with IBD contributing to muscle wasting, while the resultant sarcopenia and frailty could further exacerbate the disease course. Sarcopenia and frailty are independently associated with adverse outcomes, including hospitalizations, increased surgical interventions, and surgical complications. As therapeutic strategies for IBD evolve, understanding the nuanced relationship between inflammatory bowel disease, sarcopenia, and frailty is crucial for devising holistic management. Comprehensive care should encompass not only disease-modifying therapies but also interventions targeting frailty and sarcopenia, as they have been shown to have a significant impact not only on the disease course but also on the quality of life. Future research could focus on further elucidating underlying mechanisms, simple screening strategies, and developing targeted interventions to improve the overall quality of life for individuals grappling with the complex interplay of IBD, sarcopenia, and frailty.

Frailty and Kidney Transplant Waitlisting: A Single-Center Experience

BACKGROUND

Frailty is widely prevalent among kidney transplant (KT) candidates and is associated with poor peri and post-transplant outcomes. Whether frailty is a modifiable risk factor in KT candidates is unknown. Efforts to intervene in frailty have been hindered by a lack of a standardized approach to testing and treating frailty in clinical practice.

METHODS

Patients undergoing evaluation for kidney transplantation underwent frailty testing during their clinical visits using a combination of the Short Physical Performance Battery (SPPB) and Groningen Frailty Indicator (GFI) instruments. Scores from the SPPB and GFI were combined to stratify patients into 4 risk groups. Patients in the highest-risk groups were referred to physical therapy (PT) and returned for repeat frailty testing. Pre- and post-PT scores were compared with assessment for improvement.

RESULTS

Forty patients met the criteria for PT, of which 16 (40%) completed PT and returned for repeat frailty testing. The mean SPPB score improved from 5.88 to 8.94 after PT (P < .01). The mean GFI score improved from 5.25 to 4.06 after PT but was not statistically significant (P = .081).

CONCLUSIONS

Our unique approach of using 2 validated scores, SPPB and GFI, together addressed many components of frailty evaluation, including physical, cognitive, and psychosocial components. We used PT as a targeted intervention for addressing both the physical and non-physical impairments among frail KT candidates. Physical therapy was noted to have a positive impact on each of these components.

Nutritional Assessments by Bioimpedance Technique in Dialysis Patients

Bioelectrical impedance analysis (BIA) has been extensively applied in nutritional assessments on the general population, and it is recommended in establishing the diagnosis of malnutrition and sarcopenia. The bioimpedance technique has become a promising modality through which to measure the whole-body composition in dialysis patients, where the presence of subclinical volume overload and sarcopenic obesity may be overlooked by assessing body weight alone. In the past two decades, bioimpedance devices have evolved from applying a single frequency to a range of frequencies (bioimpedance spectroscopy, BIS), in which the latter is incorporated with a three-compartment model that allows for the simultaneous measurement of the volume of overhydration, adipose tissue mass (ATM), and lean tissue mass (LTM). However, clinicians should be aware of common potential limitations, such as the adoption of population-specific prediction equations in some BIA devices. Inherent prediction error does exist in the bioimpedance technique, but the extent to which this error becomes clinically significant remains to be determined. Importantly, reduction in LTM has been associated with increased risk of frailty, hospitalization, and mortality in dialysis patients, whereas the prognostic value of ATM remains debatable. Further studies are needed to determine whether modifications of bioimpedance-derived body composition parameters through nutrition intervention can result in clinical benefits.

Malnutrition in solid organ transplant patients: A review of the literature

Screening for malnutrition is of vital importance for solid organ transplant candidates to optimize nutrition status before transplant, to improve clinical outcomes and to inform selection committees of nutritional contraindications and risks. There are multiple criteria and screening tools available for determining malnutrition diagnosis and risk. Registered Dietitian Nutritionists use these tools for nutrition assessments to quantify the severity of malnutrition, provide patient-centered interventions, and monitor progression. Many transplant centers in the United States utilize the American Society of Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics' Adult Malnutrition Criteria, though there is limited research using these criteria specifically in the transplant population. Malnutrition, utilizing other diagnostic and screening tools, has been associated with important complications, including longer length of hospital stay, increased mortality, decreased quality of life, worsened end-stage organ progression, and decreased functional status. Malnutrition typically results from sarcopenia and cachexia, and can ultimately lead to frailty, causing further negative impacts on transplant outcomes. This literature review summarizes the current research on malnutrition in solid organ transplant candidates and provides recommendations for future research and current practice implications.

Examining the safety and effectiveness of a 4-week supervised exercise intervention in the treatment of frailty in patients with chronic kidney disease

Background

The optimal duration of antifrailty interventions and how best to deliver them to patients with chronic kidney disease (CKD) is unknown. The aim of this study was to examine the safety, feasibility and preliminary efficacy of a 4-week supervised exercise intervention on frailty in patients with CKD.

Methods

We conducted a prospective feasibility study involving patients with ≥stage 3 CKD (1 patient with stage 3 CKD, 7 patients with stage 4 CKD and 17 patients with stage 5 CKD) who were either frail or prefrail according to the physical frailty phenotype and/or had a Short Physical Performance Battery (SPPB) score ≤10. The exercise intervention consisted of two supervised outpatient sessions per week for 4 weeks (eight total sessions). Frailty and other study measures were assessed at baseline and after 4 weeks of exercise.

Results

Of the 34 participants who completed the baseline assessment and were included in the analyses, 25 (73.5%) completed the 4-week assessment. Overall, 64.0% of patients were on dialysis and 64.0% had diabetes mellitus. After 4 weeks of exercise, frailty prevalence, total SPPB scores and energy/fatigue scores improved. No adverse study-related outcomes were reported.

Conclusions

The 4 weeks of supervised exercise was safe, was associated with an excellent completion rate and improved frailty parameters in CKD patients with CKD. This study provides important preliminary data for a future larger prospective randomized study.

Clinical Trialgov

registration: NCT03535584.

Prevalence of physical frailty and impact on survival in patients with chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Frailty is common in chronic kidney disease (CKD) patients and becomes more prevalent as kidney disease progresses. This study aimed to investigate the prevalence of physical frailty and quantify the relationship between frailty and mortality risk in patients with CKD.

METHODS

PubMed, Web of Science, Embase, Cochrane Central Register of Controlled Trials, Clinicaltrial.gov, and major renal academic conferences were systematically searched, and additional references to relevant articles were manually searched. The prevalence of physical frailty and the risk of mortality based on random-effects models were assessed using percentages and hazard ratio (HR) with a 95% confidence interval (CI).

RESULTS

A total of 139 articles, including 1,675,482 participants, met the eligibility criteria for the meta-analysis. The results showed that 34.5% (95% CI 31.0 to 38.1%) of CKD patients showed signs of frailty, and 39.4% (95% CI 35.4 to 43.5%) had prefrail symptoms. Compared to non-frail patients, the risk of mortality was increased by 94.1% (95% CI 1.586 to 2.375) in frail patients and 34.5% (95% CI 1.231 to 1.469) in prefrail patients.

CONCLUSION

The high prevalence of frailty and prefrail in adults with CKD and resulting in premature death emphasize the importance of measuring frailty, which provides important prognostic information and may provide opportunities for interventions to improve the prognosis of patients with CKD.

Frailty and Clinical Outcomes in Patients Treated With Hemodialysis: A Prospective Cohort Study

Rationale and Objective

Frailty is common among people with kidney failure treated with hemodialysis (HD). The objective was to describe how frailty evolves over time in people treated by HD, how improvements in frailty and frailty markers are associate with clinical outcomes, and the characteristics that are associated with improvement in frailty.

Study Design

Prospective cohort study.

Setting and Participants

Adults initiating thrice weekly in-center HD in Canada.

Exposure

We classified frailty using a 5-point score (3 or more indicates frailty) based on physical inactivity, slowness or weakness, poor endurance or exhaustion, and malnutrition. We categorized the frailty trajectory as never present, improving, deteriorating, and always present.

Outcomes

All-cause death, hospitalizations, and placement into long-term care.

Analytical Approach

We examined the association between time-varying frailty measures and these outcomes using Cox and negative binomial models, after adjustment for potential confounders.

Results

985 participants were included and followed up for a median of 33 months; 507 (51%) died, 761 (77%) experienced ≥1 hospitalization and 115 (12%) entered long-term care. Overall, 760 (77%) reported frailty during follow-up. Three-quarters (78%) of those with frailty at baseline remained frail throughout the follow-up, 46% without baseline frailty became frail, and 23% with baseline frailty became nonfrail. Higher frailty scores were associated with an increased risk of mortality (fully adjusted HR, 1.58 per unit; 95% CI, 1.39-1.80) and an increased rate of hospitalization (RR, 1.16 per unit; 95% CI, 1.09-1.23). Compared with those who were frail throughout the follow-up, participants with frailty at baseline but improving during follow-up showed a lower mortality (HR, 0.59; 95% CI, 0.42-0.81), and a lower rate of hospitalization (RR, 0.70; 95% CI, 0.56-0.87).

Limitations

There was missing data on frailty at baseline and during follow-up.

Conclusions

Frailty was associated with a higher risk of poor outcomes compared with those without frailty, and participants whose status improved from frail to nonfrail showed better clinical outcomes than those who remained frail. These findings emphasize the importance of identifying and implementing effective treatments for frailty in patients receiving maintenance HD.

Diagnosis of Chronic Kidney Disease and Assessing Glomerular Filtration Rate

Chronic kidney disease (CKD) is a silent progressive disease. It is diagnosed by assessing filtration and markers of kidney damage such as albuminuria. The diagnosis of CKD should include not only assessing the glomerular filtration rate (GFR) and albuminuria but also the cause. The CKD care plan should include documentation of the trajectory and prognosis. The use of a combination of serum cystatin C and creatinine concentration offers a more accurate estimation of GFR. Social determinants of health are important to address as part of the diagnosis because they contribute to CKD disparities.

Physical Frailty and Functional Status in Patients With Advanced Chronic Kidney Disease: A Systematic Review

Background

With an aging population and growing number of patients with chronic kidney disease (CKD), integrating the latest risk factors when deciding on a treatment plan can result in better patient care. Frailty remains a prevalent syndrome in CKD resulting in adverse health outcomes. However, measures of frailty and functional status remain excluded from clinical decision making.

Objective

To examine the degree to which different measures of frailty and functional status are associated with mortality, hospitalization, and other clinical outcomes in patients with advanced CKD.

Design

Systematic review.

Setting

Observation studies including cohort study, case-control study, or cross-sectional study examining frailty and functional status on clinical outcomes. There were no restrictions on type of setting or country of origin.

Patients

Adults with advanced CKD, including both types of dialysis patients.

Measurements

Data including demographic information (e.g., sample size, follow-up time, age, country), assessments of frailty or functional status and their domains, and outcomes including mortality, hospitalization, cardiovascular events, kidney function, and composite outcomes were extracted.

Methods

A search was conducted using databases Medline, Embase, and Cochrane Central Register for Controlled Trials. Studies were included from inception to March 17, 2021. The eligibility of studies was screened by 2 independent reviewers. Data were presented by instrument and clinical outcome. Point estimates and 95% confidence intervals from the fully adjusted statistical model were reported or calculated from the raw data.

Results

A total of 117 unique instruments were found among 140 studies. The median sample size of studies was 319 (interquartile range, 161-893). Most studies focused on incident and chronic dialysis patient populations, with only 15% of studies examining non-dialysis CKD patients. Frailty and lower functional status were associated with an increased risk for adverse clinical outcomes such as mortality and hospitalization. The 5 individual domains of frailty were also found to be associated with poor health outcomes.

Limitations

Meta-analysis could not be performed due to significant heterogeneity between studies and methods used to measure frailty and functional status. Many studies had issues with methodological rigor. Selection bias and the validity of data collection could not be ascertained for some studies.

Conclusion

Frailty and functional status measures should be integrated to help guide clinical care decision making for a comprehensive assessment of risk for adverse outcomes among patients with advanced CKD.

Registration PROSPERO

CRD42016045251.

Cellular Senescence and Frailty in Transplantation

Purpose of review

To summarizes the literature on cellular senescence and frailty in solid-organ transplantation and highlight the emerging role of senotherapeutics as a treatment for cellular senescence.

Recent findings

Solid-organ transplant patients are aging. Many factors contribute to aging acceleration in this population, including cellular senescence. Senescent cells accumulate in tissues and secrete proinflammatory and profibrotic proteins which result in tissue damage. Cellular senescence contributes to age-related diseases and frailty. Our understanding of the role cellular senescence plays in transplant-specific complications such as allograft immunogenicity and infections is expanding. Promising treatments, including senolytics, senomorphics, cell-based regenerative therapies, and behavioral interventions, may reduce cellular senescence abundance and frailty in patients with solid-organ transplants.

Summary

Cellular senescence and frailty contribute to adverse outcomes in solid-organ transplantation. Continued pursuit of understanding the role cellular senescence plays in transplantation may lead to improved senotherapeutic approaches and better graft and patient outcomes.

Association of kidney function and albuminuria with frailty worsening and death in very old adults

BACKGROUND AND OBJECTIVES

Studies analysing the association of albuminuria and prevalent frailty in community-dwelling very old adults are scarce and lack information on incident frailty. We investigated the association of kidney function decline and increase of albuminuria with frailty worsening or death in very old adults.

DESIGN

Longitudinal analyses with biennial visits of the Berlin Initiative (cohort) Study and a frailty follow-up of 2.1 years.

SETTING/SUBJECTS

1,076 participants with a mean age of 84.3 (5.6) years of whom 54% were female.

METHODS

Partial proportional odds models were used to assess the association of estimated glomerular filtration rate (eGFR) decline and/or albuminuria (albumin creatinine ratio, ACR) with frailty worsening or death.

RESULTS

At frailty baseline, 1,076 participants with an eGFR of 50 (13) ml/min/1.73 m2, 48% being prefrail and 31% frail were included. After median 2.1 years, 960 (90%) participants had valid information on frailty transition: 187 (17.5%) worsened and 111 (10.3%) died. In the multivariable model, the odds of frailty worsening for participants with albuminuria in combination with eGFR <60 ml/min/1.73 m2 were elevated [OR (95% CI): 2.47 (1.41-4.31)] compared to participants without albuminuria and eGFR ≥60 ml/min/1.73 m2 as there was a rapid eGFR decline of ≥3 ml/min/1.73 m2 per year [1.55 (1.04-2.33)] and albuminuria trajectories six years prior [1.53 (1.11-2.10)] to frailty baseline. The odds of death for each exposure were even higher.

CONCLUSIONS

In older adults, advanced stages of CKD and albuminuria alone were associated with 2-fold odds of frailty worsening independent of death.

Comparison between FRAIL Scale and Clinical Frailty Scale in predicting hospitalization in hemodialysis patients

BACKGROUND

To assess the prevalence of frailty by the Clinical Frailty Scale (CFS) and the 5-item FRAIL scale and their association with hospitalization in hemodialysis (HD) patients.

METHODS

This was a prospective observational study. We included patients of both genders ≥ 18 years old in HD treatment for at least 3 months. Demographic, clinical, and routine laboratory data were retrieved from the medical charts. Two different frailty assessment tools were used, the CFS and the FRAIL scale. Participants were followed up for 9 months and hospitalizations for all causes were evaluated. A Venn diagram was constructed to show the overlap of possible frailty and pre-frailty. Cox regression was used to identify the association between frailty and hospitalization. The significance level was 5%.

RESULTS

A total of 137 subjects were included in the analysis. The median age was 61 (52-67) years and 60% were male. The hospitalization rate and mortality in 9 months were 22.6% and 7.29%, respectively. Regarding frailty, the overall prevalence was 13.8% assessed by CFS and 36.5% according to the FRAIL scale. In the Cox regression, frailty by FRAIL scale was associated with a 2.8-fold increase in the risk of hospitalization (OR = 2.880; 95% CI = 1.361-6.096; p = 0.006), but frailty assessed by the CFS was not associated with the need for hospitalization.

CONCLUSION

In HD patients, the FRAIL scale proved to be an easy-to-apply tool, identifying a high prevalence of frailty and being a predictor of hospital admission.

Frailty and the psychosocial components of the edmonton frail scale are most associated with patient experience in older kidney transplant candidates - a secondary analysis within the kidney transplantation in older people (KTOP) study

Background

Older people with end-stage kidney disease (ESKD) are vulnerable to frailty, which impacts on clinical and experiential outcomes. With kidney transplantation in older people increasing, a better understanding of patient experiences is necessary for guiding decision making. The Kidney Transplantation in Older People (KTOP):impact of frailty on outcomes study aims to explore this. We present a secondary analysis of the Edmonton Frail Scale (EFS) and its relationship with patient experience scores.

Methods

The KTOP study is a single centre, prospective study, which began in October 2019. All ESKD patients aged ≥60 considered for transplantation at Imperial College Renal and Transplant Centre were eligible. Frailty was assessed using the EFS and 5 questionnaires assessed patient experience and quality of life (QoL) (Short Form-12(v2), Palliative Care Outcome Scale-Symptoms Renal, Depression Patient Health Questionnaire-9, Illness Intrusiveness Ratings Scale, Renal Treatment Satisfaction Questionnaire). The EFS was divided into 4 subdomains (psychosocial, physical function, medical status, and general health) and then compared with the questionnaire scores.

Results

210 patients have been recruited (aged 60-78), 186 of whom completed EFS assessments. 118 (63.4%) participants were not frail, 36 (19.4%) vulnerable, and 32 (17.2%) were frail. Worse frailty scores were associated with poorer patient experience and QoL scores across all questionnaires. Severe deficits in the EFS psychosocial subdomain showed a statistically significant association with higher depression screen scores (coefficient 4.9, 95% CI 3.22 to 6.59), lower physical (coefficient -4.35, 95% CI -7.59 to -1.12) and mental function scores (coefficient -8.33, 95% CI -11.77 to -4.88) from the Short Form-12(v2), and lower renal treatment satisfaction scores (coefficient -5.54, 95% CI -10.70 to -0.37). Deficits in the physical function and medical status EFS subdomians showed some association with patient experience scores.

Conclusion

In the KTOP study cohort at recruitment vulnerable and frail candidates reported worse QoL and patient experiences. Severe deficits in the psychosocial subdomains of the EFS showed a strong association with patient experience and QoL, whilst physical function and medical status deficits showed a lesser association. This has highlighted specific EFS domains that may be suitable for targeted interventions to improve experiences and optimise outcomes.

Analysis of individual components of frailty: Pre-transplant grip strength is the strongest predictor of post kidney transplant outcomes

Frailty is commonly assessed during kidney transplant recipient (KTR) evaluation. However, individual frailty components may have varying impact on post-transplant outcomes. In this single-center study of 825 KTRs, we determined the association between the individual components of a modified Fried frailty score and delayed graft function (DGF), early hospital readmission (EHR), cardiovascular (CV) events, acute rejection (AR), death censored graft failure (DCGF), and death. Sum frailty ≥3 was significantly associated with EHR (aOR = 3.62; 95% CI: 1.21-10.80). Among individual components, only grip strength was significantly associated with EHR (aOR = 1.54; 95% CI: 1.03-2.31). The addition of grip strength to a model with the other four components resulted in Net Reclassification Improvement (NRI) of 20.51% (p = .01). Similarly, only grip strength was significantly associated with CV events (aOR = 1.79; 95% CI: 1.12-2.86). The addition of grip strength to a model with the other four components resulted in NRI of 27.37% (p = .006). No other frailty components were associated with the outcomes of interest. Based on our findings, handgrip strength may be an important tool while assessing frailty, mainly predicting early readmission and cardiovascular events post-transplant.

Transitions in frailty state 12 months after kidney transplantation: a prospective cohort study

BACKGROUND

Frailty is associated with several unfavorable outcomes after kidney transplantation (KTx). However, limited information is available regarding the transitions in frailty state and its components after KTx. This study aimed to evaluate the transitions in physical frailty phenotype and its components over a period of 12 months after KTx.

METHODS

In this prospective single-center cohort study, we measured physical frailty phenotype (PFP) and its components at the time of admission for KTx and 12 months after KTx. The evaluation includes five components: weakness (grip strength analysed by sex and body mass index quartiles), physical activity (kcals/week based on the Minnesota Leisure Time Physical Activity questionnaire), exhaustion (self-report using the Center for Epidemiological Studies Depression Scale), gait speed (time taken to walk 15 feet based on sex and height-specific cutoff), and unintentional weight loss (self-report of unintentional weight loss > 10 lbs in the last year). The exhaustion and physical activity components are validated in the Brazilian population. Each component is scored as 0 or 1 according to its presence or absence, and a PFP score of 3-5 defines frailty, 2 is intermediate, and 0-1 is rated as non-frail. We used the McNemar and Wilcoxon test to compare physical frailty phenotype and its components between the two periods.

RESULTS

Among 87 patients included in the study, 16.1% were classified as frail, 20.7% as intermediately frail, and 63.2% as non-frail. Sixty-four patients were included in the analysis to evaluate transitions in frailty. At the time of admission for KTx, 15.6% of patients were defined as frail compared to 4.7% of patients at 12 months after KTx (p = 0.023). Among the physical frailty phenotype components, the proportion of patients who scored in the weight loss category 12 months after KTx was significantly lower than that at the time of KTx (6.3% vs 34.4%, p < 0.001).

CONCLUSIONS

There was a 69.9% reduction in the prevalence of frail patients at the end of the 12-month follow-up after KTx. Among the components of frailty, weight loss showed a significant improvement.

A Vascular Quality Initiative frailty assessment predicts postdischarge mortality in patients undergoing arterial reconstruction

BACKGROUND

Frailty assessment adds important prognostic information during preoperative decision-making but can be cumbersome to implement into routine clinical care. We developed and tested an abbreviated method of frailty assessment using variables routinely collected by the Vascular Quality Initiative (VQI) registry.

METHODS

An abbreviated frailty score (the simple Vascular Quality Initiative-Frailty Score [VQI-FS]) was developed using 11 or fewer VQI variables (hypertension, congestive heart failure, coronary artery disease, peripheral vascular disease, diabetes, chronic obstructive pulmonary disease, renal impairment, anemia, underweight, nonhome residence, and nonambulatory status) that map to recognized frailty domains in the Comprehensive Geriatric Assessment and the literature. Nonemergent cases registered in the VQI from 2010 to 2017 (n = 265,632) in seven registries (carotid endarterectomy, n = 77,111; carotid artery stenting, n = 13,215; endovascular abdominal aortic aneurysm repair, n = 29,607; open abdominal aortic aneurysm repair, n = 7442; infrainguinal bypass, n = 33,128; suprainguinal bypass, n = 10,661; and peripheral vascular intervention, n = 94,468) were analyzed using logistic regression models to determine the predictive power of the VQI-FS for perioperative and longer term (9-month) mortality. Nomograms were created using weighted regression coefficients to assist in individualized frailty assessment and estimation of 9-month mortality.

RESULTS

The VQI-FS, using equal weighting of these 11 VQI variables, effectively predicted 9-month mortality with an area under the curve of 0.724 by receiver operating characteristic curve analysis. However, differential weighting of the variables allowed simplification of the model to only seven variables (congestive heart failure, renal impairment, chronic obstructive pulmonary disease, not living at home, not ambulatory, anemia, and underweight status); hypertension, coronary artery disease, peripheral vascular disease, and diabetes had relatively low predictive power. Adding procedure-specific risk further improved performance of the model with a final area under the curve on receiver operating characteristic curve analysis of 0.758. Model calibration was excellent with predicted/observed regression line slope of 0.991 and intercept of 5.449e-04.

CONCLUSIONS

A differentially weighted abbreviated VQI-FS using seven variables in addition to procedure-specific risk has strong correlation with 9-month mortality. Nomograms incorporating patient- and procedure-adjusted risk can effectively predict 9-month mortality. Reliable estimates of longer term mortality should assist in preoperative decision-making for vascular procedures that often carry substantial risk of mortality.

Fatigue and Quality of Life in Children with Chronic Kidney Disease

Background: This study investigates the effect of chronic kidney disease (CKD) stage on fatigue and health-related quality of life (HRQoL) in the pediatric population. Material and Methods: The PedsQL (Pediatric Quality of Life Inventory) Multidimensional Fatigue Scale (subcategories: general, sleep/rest, and cognitive fatigue) and HRQoL Generic Core Scales (subcategories: physical, emotional, social, and school functioning) questionnaires were completed by 30 patients aged from 7 to 18 years old with CKD stage 2−4, CKD stage 5 on dialysis (CKD 5D), and kidney transplantation (KTx), as well as their parents. Results: Both low “Total Fatigue” and “Total HRQoL” scores were reported in 16.7% of patients. “Sleep/Rest Fatigue”, “Emotional Functioning”, and “School functioning” were the lowest scored subcategories. CKD 5D/KTx patients presented lower “Sleep/Rest Fatigue” (p = 0.022) and, more frequently, low “School Functioning” scores (p = 0.029). The “Total HRQoL” score was correlated to the “Total Fatigue” score (rs = 0.625, p < 0.001). A low “Sleep/Rest Fatigue” score was associated with low “Physical Functioning”, “School Functioning”, and “Total HRQoL” scores (p = 0.016, p = 0.001, and p = 0.047 respectively). Parents’ HRQoL score was lower than patients’ score on “Physical Functioning” (p = 0.040) and “School Functioning” subcategories (p = 0.045). Conclusions: Fatigue and disturbed HRQoL are mostly observed in CKD 5D and KTx pediatric patients, and are associated with sleep disorders and school dysfunction. Fatigue affects HRQoL, which is perceived as more deteriorated by the patients’ parents.

Frailty, Health Literacy, and Self-Care in Patients with Chronic Kidney Disease in Taiwan

Chronic kidney disease (CKD) is a chronic and often irreversible disease that requires active self-care to mitigate adverse outcomes. This study aimed to analyze the associations of demographic and disease data, frailty, health literacy (HL), and CKD self-care (CKDSC) in patients with CKD. We conducted a cross-sectional study at two hospitals in Taiwan. A total of 144 CKD patients with a mean age of 66.8 ± 9.1 years were included in the study. Among them, 79.2% were in CKD G3, and the mean time since diagnosis of CKD was 86 ± 48 months. Approximately 62.5% were identified as non-frail. The mean of HL and CKDSC were 11.76 ± 4.10 and 62.12 ± 9.31. In multivariate linear regression analysis, age ≥ 65 years (odds ratio (OR) = 5.67, 95% confidence interval (CI) 1.59–9.75), non-frailty (OR = 2.19, 95% CI 0.02–5.40), and high critical HL (OR = 1.43, 95% CI 0.13–2.90) showed significant positive correlation with CKDSC. Therefore, management of patients with CKD should focus on the young population, reinforcing health education strategies that improve critical HL and preventing frailty that may interfere with self-care. In addition, the patient’s social support resources should be expanded to achieve the goal of CKDSC.

Role of Fracture Risk Assessment Tool and Bone Turnover Markers in Predicting All-Cause and Cardiovascular Mortality in Hemodialysis Patients

Background

Fracture Risk Assessment Tool (FRAX) and bone turnover markers (BTMs) predict fractures in the general population. However, the role of FRAX and BTMs in predicting mortality remains uncertain in hemodialysis (HD) patients.

Methods

One hundred and sixty-four HD patients stratified by low or high risk of 10-year fracture probability using FRAX. High risk of fracture was defined as 10-year probability of hip fracture ≥3% or major osteoporotic fracture ≥20%. The association of high risk of fracture and BTMs with all-cause mortality and cardiovascular (CV) mortality were evaluated using multivariate-adjusted Cox regression analysis.

Results

Eighty-five (51.8%) patients were classified as high risk of fracture based on FRAX among 164 HD patients. During a mean follow-up period of 3.5 ± 1.0 years, there were 39 all-cause deaths and 23 CV deaths. In multivariate-adjusted Cox regression, high risk of fracture based on FRAX was independently associated with all-cause mortality [hazard ratio (HR): 2.493, 95% confidence interval (CI): 1.026–6.056, p = 0.044) but not with CV mortality (HR: 2.129, 95% CI: 0.677–6.700, p = 0.196). There were no associations between BTMs and mortality risk. Furthermore, lower geriatric nutritional risk index (GNRI) was significantly associated with increased CV mortality (HR: 0.888, 95% CI: 0.802–0.983, p = 0.022) after adjusting by confounding variables.

Conclusion

High risk of fracture using FRAX was an independent predictor of all-cause mortality in patients undergoing HD. FRAX, rather than BTMs, has an important role of prognostic significance in HD patients.

[Long-term physical and psychological consequences of chronic kidney disease]

Aufgrund der verbesserten Behandlungsoptionen können Patient:innen mit chronischen Nierenerkrankungen heute deutlich länger überleben als noch vor 10 Jahren. Das Überleben ist für die Betroffenen jedoch immer mit einem Verlust an Lebensqualität verbunden. In diesem Beitrag wird eine kurze Übersicht über die körperlichen und psychischen Erkrankungsfolgen, Begleiterkrankungen und Therapienebenwirkungen bei chronischen Nierenerkrankungen gegeben. Auf bisher bekannte Auswirkungen der COVID-19-Pandemie wird hingewiesen. Abschließend wird aufgezeigt, wie die Langzeitbehandlung weiterentwickelt werden sollte, um die Lebensqualität der Patient:innen zu erhöhen.

Funktionseinschränkungen der Niere haben aufgrund der Kontamination des Blutes mit harnpflichtigen Substanzen (Urämie) schwere Auswirkungen auf den Gesamtorganismus. Zusätzlich sind die Patient:innen von Nebenwirkungen betroffen, die im Zusammenhang mit der medikamentösen Therapie, Dialyse oder Nierentransplantation auftreten können. Patient:innen und Angehörige sind einer großen psychischen Belastung ausgesetzt. Infektionen mit SARS-CoV‑2 können die Nierenfunktion beeinträchtigen und auch die Prognose einer bereits bestehenden Erkrankung verschlechtern.

Die ganzheitliche Versorgung der Patient:innen mit chronischen Nierenerkrankungen muss neben der medizinischen Versorgung auch die psychologischen und psychosozialen Aspekte berücksichtigen. Nephrologie und Psychonephrologie müssen Hand in Hand weiterentwickelt werden, um die medizinische Versorgung und Lebensqualität der betroffenen Patient:innen zu verbessern.

Frailty as an Independent Risk Factor for Depression in Patients With End-Stage Renal Disease: A Cross-Sectional Study

Background

Depression confers substantial disease burden globally, especially among those with chronic kidney disease (CKD). The presence of depression significantly impairs one's quality of life. Risk factors for depression in patients with CKD remain under-appreciated, and whether frailty, a geriatric phenotype, constitutes a risk factor for depression in this population is unknown.

Methods

We prospectively enrolled patients with end-stage renal disease (ESRD) undergoing hemodialysis for >3 months from National Taiwan University Hospital Yunlin Branch between 2019 and 2021. Clinical, physical, functional, and performance parameters were recorded, followed by frailty/sarcopenia assessment. Depression was screened for using the Geriatric Depression Scale. We analyzed the independent relationship between frailty and depression in these patients, using multiple regression analyses.

Results

Totally 151 patients with ESRD were enrolled (mean 61.1 years, 66.9% male), among whom 16.6% had screening-identified depression. ESRD participants with depression did not differ from those without regarding most parameters except serum creatinine, functional indices, and sarcopenia/frailty status. We found that having greater frail severities was independently associated with a higher probability of depression; having FRAIL- (odds ratio [OR] 5.418) and SOF-based (OR 2.858) frailty independently correlated with a higher depression probability. A linear relation exists between a greater frail severity and the probability of depression. Using a more relaxed criterion for detecting depression, higher SOF scores remained significantly associated with an increased depression risk.

Conclusions

In patients with CKD, frailty independently correlated with a higher probability of having depression. Strategies aiming to attenuate frailty may be able to benefit those with depression simultaneously in this population.

Daily Step Counts in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Observational Studies

Background

Physical inactivity is an essential factor in the prognosis of patients with chronic kidney disease (CKD). Daily step count is a straightforward measure to assess physical activity levels. Understanding the step counts among different CKD stages is essential to change sedentary behavior.

Objectives

This systematic review and meta-analysis aimed to investigate the daily step counts in patients with CKD at a different stage.

Design

A systematic review and meta-analysis.

Data Sources

The literature search was performed in PubMed, Embase, and Web of Science from inception to November 3rd, 2021.

Review Methods

Observational studies (cross-sectional, case-control, or cohort studies) reported specific values of step counts in CKD patients by the wearable device were included. A random-effects model was used to pool the data. Subgroup analysis explored differences in outcomes by stage of CKD. Heterogeneity between studies was assessed using the χ2 test of Cochrane's Q statistic. A contour-enhanced funnel plot was conducted to investigate publication bias. Univariate and multivariate meta-regression was conducted to examine possible sources of heterogeneity.

Results

Twenty-eight articles were identified and used for quantitative analysis. The result showed that the daily step count in patients with CKD was 4642.47 (95% CI: 4274.18–5010.76), and significantly lower than the healthy population. Subgroup analysis revealed that the step counts decreased before dialysis, dropped to a freezing point at the hemodialysis phase, and increased after kidney transplantation. Meta-regression analysis showed that daily step counts were relatively higher in the Americas or younger than 60 or kidney transplant recipients.

Conclusion

The status of daily step counts in patients with CKD decreases with CKD severity and increases after kidney transplantation. Although studies have begun to focus on strategies to improve step counts in patients with CKD, future studies should focus more on step counts in pre-dialysis patients and changing their physically inactive lifestyle early to alleviate deteriorating renal function.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=291551, identifier: CRD42021291551.